What is a Grievance?
A grievance is defined as an expression of dissatisfaction about any matter other than an adverse benefit determination (a decision not made in your favor).Examples of grievances include:
- Not being able to find a doctor;
- Trouble getting an appointment; or
- Not being treated fairly by someone who works at Molina or at your doctor’s office.
An adverse benefit determination (a decision not made in your favor) is:
- Limiting or denying services;
- Reducing services;
- Suspending services;
- Terminating services; or
- Denying payment for services;
- Failing to provide services in a timely manner;
- Failing to resolve appeals and grievances within timeliness guidelines;
- For a resident of a rural area with only one (1) Managed Care Organization in the area, the denial of a request to exercise his or her right to get services outside the Molina network; or
- The denial of a request to dispute a financial responsibility, including cost sharing, copayments, premiums, deductibles, coinsurance, and other member financial responsibilities.
- Call Member Services
- Write a letter
- Fill out the Member Grievance Request Form
- Your first and last name
- Your address and telephone number
- Your email address
- Your Molina Member ID number, which is on the front of your Member ID Card
- Description of the issue
- Your signature
How to File a Grievance
A grievance may be filed at any time. To file your grievance, you can:
Mail the letter or form to:
Attention: Member Appeals & Grievances
PO Box 40309
North Charleston, SC 29423-0309
Phone: (855) 882-3901
You can also fax the letter or form to (877) 823-5961, Attn: Member Appeals & Grievances.
You, your authorized representative (this can be a friend, family member, attorney or a provider) may file a grievance orally or in writing for you. Providers and other authorized representatives must have your written consent to file an appeal on your behalf.
If you are sending us a letter about your grievance or completing the form, you should include:
Member Grievance Handling
When you file a grievance we will let you know that we received it within five (5) business days. We will resolve your grievance as quickly as possible, but no later than ninety (90) calendar days from the date your grievance was received.
You can ask Molina to extend the timeframe to resolve your grievance by up to fourteen (14) calendar days. Molina can also extend the timeframe to resolve your grievance by up to fourteen (14) calendar days if Molina thinks that the delay is in your best interest. If Molina extends the timeframe, we must be able to explain to SCDHHS how the delay is in your best interest. We will call you and a letter will be sent to you informing you of the extension and why the delay is in your best interest. If Molina extends the timeframe, the letter will also include information about your right to file a grievance about extending the timeframe.